Pharmacy - Contraception Consultation

PATIENT DETAILS:
Name: Mr. Carter
Phone number: 
Personal Health Number (PHN): 

GENERAL:
PharmaNet has been checked. Eligibility documented.

Objective:
REASON FOR VISIT:
Contraceptive Counselling

ASSESSMENT:
Mr. Carter presents for a contraception consultation. No information available regarding previous use of contraception, including pharmacological or non-pharmacological methods, start date, duration, side effects, or reasons for discontinuation.

No information available regarding current sexual activity or sexual history.

No information available regarding menstrual cycles, regularity, or date of last menstruation.

No information available regarding family history of deep vein thrombosis, breast cancer, cervical cancer, ovarian cancer, endometrial cancer, or colorectal cancer.

No examination findings or observations documented.

Subjective:
PAST MEDICAL HISTORY:
No prior use of SNRIs or similar medications. No information available regarding migraines, acne, or past deep vein thrombosis.

RED FLAGS/REFERRAL INDICATIONS:
No active suicidal ideation.

ALLERGIES:
No information available.

CURRENT MEDICATIONS:
No information available.

Assessment:
DIAGNOSIS:
Contraceptive counselling

Plan:
RECOMMENDATIONS:
- No patient education regarding birth control or side effects documented.
- No contraceptive prescribed.

MONITORING/FOLLOW UP:
- Follow up in 2-3 months to assess for any side effects of treatment. Mr. Carter advised to return for follow up sooner if he has any concerns regarding side effects.
- He was informed about signs and symptoms that require urgent medical assistance, such as leg pain, redness, and swelling, or chest pain and shortness of breath.
- 

Date:
2026-02-02

PHARMACY INFORMATION:
Pharmacy name: 
Pharmacy phone number: 
Pharmacy address: 
Pharmacist name: 
Pharmacist license number: